What is ADHD?

Attention deficit hyperactivity disorder (ADHD) is a very common
condition, usually present in childhood and often continuing through
adulthood. Deficit in paying attention is the most common feature.
However, hyperactivity and impulsiveness are also present to a lesser
degree. ADHD is NOT antisocial behavior such as defiance or
aggressiveness but is more like a related disorder, deficient emotional
self-regulation (DESR).

Classic ADHD symptoms are trouble paying attention, excessive
physical activity and poor impulse control. ADHD patients also display
brief anger, impatience and frustration in response to minor
inconveniences or disappointments which other people would show less
extreme reactions to. These types of reactions make ADHD more similar to
DESR, but differentiate ADHD from mood disorders which are
characterized by pervasive and specific emotions.

The disorder used to be called attention deficit disorder (ADD) but
was changed to the current term in 1994 by The American Psychiatric
Association (APA). Europeans and others that use the World Health
Organization (WHO) classification system, call it hyperkinetic disorder (HKD) or deficits in attention, motor control and perception (DAMP).

The new term, ADHD, is a generic or umbrella term, divided into types:

predominantly inattentive

predominantly hyperactive/impulsive

combined inattentiveness and hyperactivity.

Sub-threshold types, including distractibility, may occur as well. Mainly though, this neuropsychological disorder is primarily one of lack of focus or paying attention. Over time, even those with a hyperactive component will gradually overcome or lose the hyperactivity, while inattentiveness will persist.

Not being able to pay attention to tasks or to people confers a
significant disability, both as children and as adults. This functional
impairment can create havoc for the individual, the family, the school
and work environment. Because of the social stigma, individuals may feel
shame or worthlessness, and develop anxiety or other mood disorders in
addition to the ADHD. Because ADHD often begins in childhood and
persists into adulthood, the disorder is considered chronic and must be
managed lifelong for a large majority of sufferers.

However, new research suggests that this chronic, social
stigma-bearing disorder may be misinterpreted. The “disorder” may be a
variant in temperament and not a defect. Research in 2006 showed
individuals with ADHD had higher levels of creativity than others. This
scientific research was conducted using laboratory measures of
creativity. Researchers have now expanded the study to include real life
achievements. They have found that people with ADHD think differently
than others and prefer to generate ideas rather than carry them out.
This new interpretation may be useful for ADHD patients in changing
perceptions of themselves. The new findings may also reduce medication
use and encourage schools and workplaces to find better ways to use the
talents of hyperkinetic people.

Attention Deficit Disorder Epidemiology

Population studies in different countries have found similar
prevalence rates. Adults are diagnosed at a rate of 3-6 percent.
Children are diagnosed at a rate of 3-8 percent of the general
population. Males are more often diagnosed than females. Research
suggests this disparity is due to the disruptive, attention gaining
behavior of boys which brings them into the spotlight and into the
clinician’s office. Girls, in contrast, are more likely to be
inattentive, which keeps them below the radar, but still quietly
suffering. A U.S. study showed that out of the diagnosed cases of adult
ADHD, only 39 percent were female, while 61 percent were male. Most ADHD
cases are in the 18-24 year old age group, or 1 in 2 of all diagnosed
cases.

Ethnic rates may be unclear. In America, black children are more
likely than white children to be diagnosed, while Hispanic children have
the least incidence. These rates may be due to economic conditions,
insurance status and access to care. Rates according to country are also
unclear due to the differing manner of characterizing and classifying
the disorder.

Etiology

ADHD seems to be a heritable disorder or a genetic predisposition.
Genes thought to be responsible are dopamine and serotonin genes
including:

D2, D4, D5 dopamine receptor genes

dopamine beta-hydroxylase gene

dopamine transporter gene

SNAP-25 gene

serotonin transporter gene

The shape and function of some brain regions including the parietal
cortex, inferior parietal lobe, superior temporal sulcus, and reticular
activating system have differences compared to “normal” brains. The
prefrontal cortex in the brain downregulates or reduces the production
and/or transport of the neurotransmitters dopamine and norepinephrine
(noradrenaline). The premotor cortex and the superior prefrontal cortex
show deficits in glucose metabolism. The anterior cingulate demonstrates
reduced activation as well. Children with a smaller caudate nucleus in
the subcortical region of the brain have ADHD symptoms.

ADHD Complications

The combination of ADHD and poor emotional control, acts to
functionally impair individuals in their tasks and their relationships
with others. ADHD becomes more and more isolating and frustrating as the
impairment and the person develops over time.

ADHD causes functional impairment including:

Verbal learning

Non-verbal memory

Reading

Writing

Paying bills on time

Problem solving

Risk taking – gambling and sexual escapes.

Substance abuse – females especially, and males of all races are 2-3 times more likely to use cigarettes, alcohol and drugs.

Accidents and motoring offences – reductions in vigilance, motor
inhibition and hyperactivity make ADHD patients dangerous on the roads.

Lower occupational status and less productivity – workers with ADHD
produce about 22 less days per year of work. Restlessness may cause
people to seek more menial, low-paying but active jobs.

Lower educational level – ADHD can delay entrance into kindergarten
which sets the tone for a lifetime of underachievement. Those with ADHD
symptoms are less likely to complete secondary school, have lower levels
of completed education, and spend a longer time achieving degrees.

Criminal offenses – as many as 25% of criminal offenses may be
perpetrated by ADHD patients due to the stress of having ADHD and
environmental factors.

Poor emotional control causes relationship difficulties including:

Listening – other people may feel frustrated by the inattentiveness.

Being oppositional or defiant – teachers, bosses and co-workers often bear the brunt of ADHD behavior.

Attention Hyperactivity Deficit Disorder Diagnosis

Screening Tools

Screening for ADHD can be performed at any age as part of regular
checkups with a family physician, at a psychiatric interview or in the
presence of symptoms indicating ADHD. Studies have shown that primary
care physicians are less suitable than psychiatrists to diagnose ADHD.
However, because of the nature of ADHD, its chronic course and its
impairment in different settings, a team approach is often necessary and
includes the patients, parents, siblings, life partners, the
pediatrician or physician, therapists, teachers and employers.

Multiple screening instruments can help differentiate symptoms,
subtypes and identify accompanying mood disorders. Self-screening tools
are also available but they cannot take the place of a proper evaluation
by a qualified psychiatrist. Discovery of patterns of ADHD episodes
over the lifetime can alert a physician more than screening methods.
Typical questions include the age at onset, the course of the illness,
episode characteristics, and family history. Screening instruments may
include but are not limited to:

ADHD Rating Scale

Conners Adult ADHD Rating Scale

Brown Attention Deficit Disorder Scale

WHO Adult ADHD Self-Report Scale

Adult ADHD Self-Report Scale

Wender Utah Rating Scale

Mood Disorder Questionnaire (MDQ)

Bipolarity Index

Composite International Diagnostic Interview (CIDI)

Bipolar Spectrum Diagnostic Scale (BSDS)

Primary Care Evaluation of Mental Disorders (PRIME-MD)

Patient Health Questionnaire (PHQ-9)

Patient Health Questionaire (PHQ-2)

Diagnostic Considerations

ADHD is diagnosed based on clinical history and not psychological
testing because the disorder is functional/dysfunctional in nature and
not mood related primarily. Factors for proper diagnosis for adults or
children depending on the situation include:

Presence of risk factors.

Functional impairment across 2 or more settings (school and home) – impairment criteria must be met for a diagnosis of ADHD.

ADHD symptoms onset prior to age 7 years – children often display
symptoms before the age of seven and as young as 2 or 3 with hyperactive
symptoms. Inattentiveness is apparent when the child begins school.

Past or present academic or work dysfunction – students or workers
who achieve below their capabilities, have low grades or performance
reports, and disciplinary problems.

Clinical history – includes reports from parents, teachers, co-workers and employers.

Screening questionaires – parents and teachers can fill out these questionaires.

Self-reports and testing – adult people with ADHD report that they
are disorganized and unfocused. Testing for short-term memory, long-term
memory and word-finding abilities can confirm in adults or children. A
history can be obtained from the patient including childhood conditions
and impairments, but patients often overestimate inattention.
Confirmation from a living relative or sibling is necessary or the
patient’s self-report is taken less seriously.

Time Course – the impairment and symptoms can be identified over
time. If life stresses, mood symptoms or other mitigating factors are
found during the time of the ADHD symptoms, then ADHD is placed lower in
significance. Specific mood disorders, health disorders or life
stresses are identified and treated first before the ADHD.

Neuropsychological testing – not diagnostic in and of itself, but as
an adjunct and useful in isolating attentional impairment by ruling out
cognitive or mood deficits, identify processing deficits, intelligence
level and learning disabilities.

Medical testing – not diagnostic, but useful for identifying medical
conditions like anemia or hypertension which may cause ADHD. Blood and
urine can be useful in identifying substance abuse. EEG and brain
imaging tests are used to identify seizures and head trauma.

Differentiating Diagnosis

These symptoms, conditions and disorders may accompany ADHD but are not primary symptoms and indicate a cause other than ADHD:

Accidents

Aggression that hurts people or animals.

Anxiety

Arguments/fights

Compulsive behaviors

Delusions – false beliefs

Depression – chronic depressed mood or a loss of interest in usual activities.

Six or more of the following symptoms of hyperactivity/impulsivity
have persisted for at least 6 months to a degree that is maladaptive and
inappropriate.

Often fidgets with hands or feet, or squirms in seat.

Often leaves seat in classroom or in other situations in which remaining in seat is expected.

Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, it may be limited to subjective
feelings of restlessness).

Often has difficulty playing or engaging in leisure activities quietly.

Is often “on the go” or often acts as if “driven by a motor.”

Often talks excessively.

Often blurts out answers before questions have been completed.

Often has difficulty waiting their turn.

Often interrupts or intrudes on others (butts into conversations or games).

Classification

Three (3) specific subtypes of ADHD are:

ADHD, combined type: if both criteria IA and IB are met for the past 6 months.

ADHD, predominantly inattentive type: if criterion IB is not met for the past 6 months.

ADHD, predominantly hyperactive-impulsive type: if criterion IB is met, but criterion IA is not met for the past 6 months.

ADHD in partial remission – those who have overcome some aspects of the disorder but retain some symptoms.

ADHD not otherwise specified – impairment is significant but does not meet full criteria and patient can benefit from treatment.

ADHD Treatment

A greater awareness about ADHD can include personnel at school, work,
family relationships, friendships, and activities. Early identification
and treatment is important to increase the chances in school and work,
and to limit developing emotional and conduct disorders. Treatment is
often individualized and will change over time according to
developmental stages. Treatment advice for a child will differ than for a
teenager. For example, a teenager should be able to pay attention
longer or sit in the chair longer than a pre-schooler and treatment
advice is adjusted accordingly. Treatment is also monitored and adjusted
for maximum efficiency and compliance, with a limitation of side
effects.

Psychoeducation

A first line treatment for patient, family, school personnel and
workplace, especially for preschoolers before medication is tried.
Everyone is informed of symptoms, probable course of the disorder, and
options for treatment. Discussions include the types of accommodations
and individualized plans that will be made for a student or worker.
Psychoeducation offers clear, non-technical language and proven
strategies for accommodations.

Medications

Dosing starts at the lowest level possible with monitoring to
determine efficacy, side effects and addiction. Preparations can be
increased in dosage if necessary. Long-acting doses are preferred in
order to have a smooth uptake and measured release over the course of
the day. Long-acting doses are usually given once a day and reduce the
need to take medication at school or work, and increase compliance by
not needing to remember many doses.

Medications may become less efficient over time. Individuals will
vary in reaction to medication according to metabolism, absorption and
sensitivity, so weight or size is just a beginning in determining
dosage. The delivery will also vary according to medication,
manufacturer, and delivery mechanism.

Medication type can be switched if necessary and multiple attempts at
pharmacological intervention often occur, especially in the cases of
accompanying psychological disorders.

Medication is sometimes stopped after 6 months to reevaluate the
patient, and resumed if necessary. The following medications are listed
in order of preference for treatment of ADHD, although individual
doctors may prefer a different order:

1/ Methylphenidate (brand names Ritalin or Concerta) and Amphetamine (brand name Adderall)
– first-line pharmacological agents of choice. Stimulants are favored
over behavioral therapy according to large scale, repeated studies. Most
patients (65-75%) respond to these agents because of their calming and
focusing effect. They work by restoring dopamine levels and efficiency
in the brain.

2/Atomoxetine – a
non-stimulant medication with a low abuse or addiction potential. It
works by inhibiting noradrenaline reuptake. Dosing is once or twice
daily but can take several weeks for the full effects to be seen. A very
small risk of suicidal ideation is documented but no completed
suicides. Some cases of liver damage have been reported, as well as
increases in heart rate and blood pressure.

3/ Alpha-2-adrenergic agonists – used to
treat symptoms of ADHD, comorbid aggression, stimulant-induced tics and
insomnia and are usually are more effective for the
hyperactive-impulsive ADHD than for inattentive ADHD. Heart and blood
pressure should be monitored and side effects may include sleepiness,
dry mouth, and dizziness.

4/ Tricyclic antidepressants (TCAs) – may be counterindicated for those with bi-polar co-morbidity. Cardiotoxicity, sleepiness, and constipation are among the side effects. Overdoses can be fatal so those with suicidal ideation should not take TCAs.

5/ Bupropion (brand name Wellbutrin) – those with seizure risks should not take this medication. Doses are often divided to enhance safety.

Behavioral Therapy

Medication combined with strategies for the patient, parents and
families may provide optimum treatment for ADHD. Patients with
accompanying psychological disorders, life stresses and substance abuse
may be particularly receptive to behavioral therapy. Coordination with
school and work includes communication, positive feedback, and negative
consequences like time-outs. One such program for children is called The Incredible Years, a basic parent training program.

Cognitive Therapy

Talking to a counselor may help sort through the emotional issues
that accompany ADHD, especially since ADHD often interferes with social
relationships. Family and life partners may be brought into therapy as
an intervention with family members can be very helpful to increase
positive outcomes. Patients need to interview potential therapists in
order to find one they feel comfortable with. One form of therapy is not
better than another but rather depends on the personalities of the
therapist and patient meshing together.

Monitoring

Patients on medication should follow up with the physician on a
regularly scheduled basis, weekly or bi-weekly initially, monthly or
quarterly thereafter. Medication efficacy, side effects, mood, substance
abuse and relationship issues can be addressed during these
appointments, as well as any new issues or developmental changes.

Changes might include the onset of puberty, pregnancy or other medical issues.

Medication issues may include mania, insomnia, or heart problems.

Co-morbid conditions may include depression, eating disorders and substance abuse.

Life Skills

Interventions which enhance organization, time management, planning
skills and problem solving can be helpful. While most people have time
management issues and can learn better skills, targeted programs for
adult ADHD patients show success in diminishing ADHD symptoms. In
addition, people with ADHD can focus and pay attention to things that
they like to do, so pursuing schooling, work or activities with a
perceived high reward is an excellent strategy.

Social buffering and an emphasis on important personal relationships
can provide a positive effect on ADHD symptoms. Informal networks of
family members, co-workers, friends and religious counselors can provide
support and help in meeting life satisfaction goals.

Sleep

Even a small amount of sleep deprivation causes children with ADHD to
lose focus. Scientists have found that even one hour of sleep loss per
week can impact a child’s ability in many measures of ADHD symptoms.
Current recommendations for sleep vary with age, but are generally
within a 7-9 hours of sleep per night.

Diet

Currently, advice is mixed on the elimination of sugar and food dyes
from the dietary intake. Some studies and some experts recommend
elimination of sugar and dyes, while others disagree. More studies are
needed to elicit agreement. However, elimination is not harmful and can
be helpful.

No dietary strategies are proven to help with ADHD symptoms. However,
anemia is considered a causative agent for ADHD, so a diet rich in
bioavailable iron is recommended. A balanced diet is important for all
ages, especially for children and adolescents. Omega 3 fatty acids
supplementation may be moderately effective.

Exercise

Exercise increases cognitive skills for people of all ages. Task
perseverance and memory increases immediately after exercise and may
have long-term benefits as well. Children who exercise show lower
symptoms of ADHD. Exercise increases a sense of mastery and a sense of
self-worth, and gives a natural lift in mood. Yoga, strength training,
balance exercise and even massage can reduce tension, fatigue and
anxiety.

Behaviors to Avoid

Alcohol, cigarettes and drug use is common in ADHD patients of all
subtypes, ages, and races. Elimination of substance use may decrease
symptoms, increase medication efficiency and increase long-term health
outcomes.

Barriers to Treatment

Many patients under medical or psychiatric care do not take their
medications as directed. Stopping medications or taking medication
inappropriately may reduce positive outcomes and cause a return of the
symptoms of ADHD. Regular visits with the physician are necessary to
monitor medications, adjust dosage and monitor for side effects.

Prognosis

The prognosis for ADHD patients is very good with medication, life
skills training, parent education and support. Even those patients with
accompanying mood disorders improve with treatment. While the quality of
life depends on the severity of symptoms, treatment is effective in a
majority of cases.

Emerging Possibilities

Green Play Therapy

A new study reports that children who play in surroundings
approximating nature, have less severe ADHD symptoms. Children who have
opportunities to spend time in landscapes filled with trees and grass
can improve concentration and impulse control.

Horseback Riding

A very small quasi-experimental study has demonstrated a novel form
of therapy for children. Five children aged 10-11 years old with ADHD
participated in horseback riding for one hour, twice a week for eight
weeks. Subjects improved in measures related to social relationships,
quality of life, and motor performance.

Early Identification

A new way to identify ADHD patients has been found in unintentional
and unnecessary movements. ADHD patients were filmed while being asked
to tap the fingers of their dominant hand. Patients with ADHD had fifty
times the amount of movement in the same muscles on the opposite side of
the body, as compared to normal subjects.

Saliva testing is new non-invasive method for testing for ADHD by
measuring oxidative stress. Patients with ADHD had higher levels of
salivary protein thiols and pseudocholinesterase levels compared to
controls. Magnesium levels in ADHD patients are decreased in comparison
to controls.

Related Conditions

Generalized Anxiety Disorder – characterized by a lack of control in managing worry and tension.

Bi-polar Disorder – alternating moods between mania and depression, but never a normal mood.

Social Anxiety Disorder – the presence of other people causes persons with this disorder to become overvigilant to their own performance, which leads them to avoid social situations.

Personality Disorders – types of personality that feature a narrow range of feelings, thoughts, and behaviors that do not show adaptability in most situations. A personality becomes fixed in a particular maladaptive psychiatric condition.

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